American Journal of Transplantation 2013; 13: 819–820 Wiley Periodicals Inc.
Letter to the Editor
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Copyright 2013 The American Society of Transplantation and the American Society of Transplant Surgeons doi: 10.1111/ajt.12032
Meningococcal Sepsis Complicating Eculizumab Treatment Despite Prior Vaccination To the Editor: Recently, the monoclonal antibody against complementfactor C5, eculizumab, was successfully applied in the treatment of recurrent atypical hemolytic-uremic syndrome (aHUS) in renal transplant recipients (RTR) (1). Guidelines for its use include meningococcal vaccination prior to treatment. Late complement–pathway– component deficiencies predispose to meningococcal infections by the absence of meningococcal lysis via classical and alternative pathways (2). Consequently, protection against meningococcal disease by antibody-mediated killing becomes essential. However, vaccination of patients using immunosuppressive drugs may be ineffective (3,4). Different immunosuppressive regimens vary in their effects on humoral responses after vaccination. Previously, we demonstrated that RTR treated with prednisolone and everolimus mount adequate humoral vaccination responses, measured by ELISA, against immunocyanin, tetanus-toxoid (TT) and pneumococcal polysaccharide (PPS). In contrast, treatment with mycophenolic mofetil (MMF) and prednisolone completely disturbed vaccination responses against these same antigens (3). Although immune responses after vaccination are generally used as markers of efficacy of vaccination, they are not synonymous with protection. Furthermore, in immunocompromised patients vaccination-induced responses may wane rapidly. Protection provided by vaccines after renal transplantation may be limited in quality and/or duration. This is illustrated by the following case. A 19-year-old woman with a known factor H mutation received her third renal transplant in February 2008. Immunosuppressive therapy consisted of basiliximab, prednisolone, MMF and tacrolimus. To prevent recurrence of HUS, she was treated with plasma exchange (PE). From January 2009 onward, PE was substituted by eculizumab 2 weekly because of allergic reactions to plasma constituents. Despite vaccination with meningoR (ACYW135) coccal polysaccharide vaccine Mencevax before start of eculizumab treatment, she developed meningococcal sepsis caused by serotype W135 18 months later, when she presented with sudden onset of headache, myalgia, nausea, vomiting and diarrhea. Upon examination, our patient was hypotensive (blood pressure 60/40 mmHg), tachycard (pulse 120/bpm) and had a temperature of 38.8◦ C. Aggressive resuscitation was initiated including empiric antibiotics and she fully recovered.
Figure 1: N. meningitides-specific IgG antibodies against serotype A, C, Y and W135 in a renal transplant recipient before and several time points after meningococcal vaccination: before the first vaccination with a polysaccharide meningococcal vaccine (ACYW135) (a+b) and 1 week after the first vaccination (c). One month after vaccination eculizumab treatment was initiated. N. meningitides-specific IgG antibodies were analyzed at 2 (d) and 16 months (e) after vaccination (5). Eighteen months after vaccination, the patient developed meningococcal sepsis (W135) and N. meningitides-specific IgG antibodies were analyzed 7 weeks (f) after this meningococcal sepsis. Five months after recovering of her meningococcal sepsis, the patient received a second vaccination with a polysaccharide meningococcal vaccine (ACYW135). Before (g) and 2 weeks after (h) this vaccination N. meningitides-specific IgG antibodies were analyzed. Seven months after the second meningococcal vaccination, the patient received a conjugated meningococcal vaccine (ACYW135). Before (i) and 2 months after this vaccination (j) N. meningitides-specific IgG antibodies were analyzed.
In retrospect, we analyzed serum IgG antibodies against meningococci before and several time points after vaccination. Serotype C antibodies were present in low titer, but no serotype A, Y and W135 antibodies. A second vacR administered 5 months after her cination with Mencevax sepsis, and a third vaccination with meningococcal conR (ACYW135) 12 months later, jugate vaccine Menactra did not elicit a significant rise in antibodies against any of the meningococcal serotypes (Figure 1). She also appeared unable to mount humoral responses after vaccination with TT, PPS or influenza. A second 26-year-old female RTR treated with prednisolone, MMF and tacrolimus who started eculizumab treatment because of HUS recurrence resistant to PE, also failed to mount humoral responses R (data not shown). after vaccination with Mencevax 819
Letter to the Editor
In conclusion, administration of eculizumab in patients receiving immunosuppressive therapy may be complicated by meningococcal disease despite prior vaccination. We advise not to rely on efficacy of meningococcal vaccines in eculizumab-treated patients receiving immunosuppressive therapy. Preferably, these patients should be vaccinated prior to initiation of immunosuppressive therapy. Furthermore, they should be readily treated with antibiotics as soon as suspicion of meningococcal disease arises and/or chemoprophylaxis with ciprofloxacin should be considered. G. H. Struijka, ∗ , A. H. M. Bouts b , G. T. Rijkers c , E. A. C. Kuin a , I. J. M. ten Berge a and F. J. Bemelman a a Renal Transplant Unit, Department of Nephrology, Division of Internal Medicine, Academic Medical Center, University of Amsterdam, the Netherlands b Department of Pediatric Nephrology, Emma Children’s Hospital/Academic Medical Center, University of Amsterdam, the Netherlands c Department of Medical Microbiology and Immunology, St. Antonius Hospital, Nieuwegein and Department of Sciences, Roosevelt Academy, Middelburg, the Netherlands ∗ Corresponding author: G. H. Struijk,
[email protected]
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Disclosure The authors of this manuscript have no conflicts of interest to disclose as described by the American Journal of Transplantation.
References 1. Davin JC, Gracchi V, Bouts A, Groothoff J, Strain L, Goodship T. Maintenance of kidney function following treatment with eculizumab and discontinuation of plasma exchange after a third kidney transplant for atypical hemolytic uremic syndrome associated with a CFH mutation. Am J Kidney Dis 2010; 55: 708–711. 2. Ram S, Lewis LA, Rice PA. Infections of people with complement deficiencies and patients who have undergone splenectomy. Clin Microbiol Rev 2010; 23: 740–780. 3. Struijk GH, Minnee RC, Koch SD, et al. Maintenance immunosuppressive therapy with everolimus preserves humoral immune responses. Kidney Int 2010; 78: 934–940. 4. Pescovitz MD, Torgerson TR, Ochs HD, et al. Effect of rituximab on human in vivo antibody immune responses. J Allergy Clin Immunol 2011; 128: 1295–1302. 5. Lal G, Balmer P, Joseph H, Dawson M, Borrow R. Development and evaluation of a tetraplex flow cytometric assay for quantitation of serum antibodies to Neisseria meningitidis serogroups A, C, Y, and W-135. Clin Diagn Lab Immunol 2004; 11: 272–279.
American Journal of Transplantation 2013; 13: 819–820
